Methotrexate: Pharmacist Error

An error occurred at a Safeway pharmacy in which methotrexate, a drug used for chemotherapy, treatment of severe inflammatory disorders such as rheumatoid arthritis, and abortions, was dispensed to a pregnant woman. It is important to understand that the usual patient who comes to a retail pharmacy for methotrexate is getting it for inflammatory conditions. The doses are normally a few to several 2.5 mg tablets, (although larger sizes are now available), and the drug might come in a dose pack called Rheumatrex. It is usually taken once per week for those conditions.

This error occurred due to a mix-up in which Mareena Silva, of Ft. Lupton, CO, received a prescription intended for another patient, supposedly with the same last name and a similar first name.

Unanswered in most news coverage is whether Silva took a single dose of several tablets, which is frequently characteristic of orally administered methotrexate treatments, and is not characteristic of most oral antibiotic treatments. The usual dose for rheumatoid arthritis is quite a bit lower than the dose to kill a human embryo.

Yet to be found is whether Ms. Silva was given methotrexate rescue treatment (leucovorin calcium) which might counteract the assault by methotrexate upon folate metabolism to its active form, which is the basis of its toxicity to the human embryo or fetus, (and various rapidly dividing cells throughout the body).

Safeway is acknowledging their liability, and has offered to pay all medical expenses which result from this error.

Error prevention: At many retail pharmacies, scanning, name and birth date checks are eliminating much of the possibility of these errors, but if the two Silva prescriptions were back to back and went into wrongly tagged bags before dispensing, nothing but extensive counseling with the bag opened and drug visible would have stopped this error. We know that many patients refuse such counseling, and that often there is not time to carry out extensive counseling on the use of medications at the pharmacy.

Expert commentary: This is a job for a person with retail pharmacy experience, as well as practical clinical knowledge. The media chosen point man of the day is one "distinguished service" professor from the University of Florida, Paul Doering M.S. (ABC news has given his credentials incorrectly.) Doering is NOTquoted by ABC as suggesting THE RESCUE TREATMENT for methotrexate. As expected is the media favorite recommendation of abortion, from ABC: "Doering, who did his masters thesis on the drug," [way back in 1975] "said methotrexate is the poster child for why certain medicines shouldnt be used in pregnancy. Its such a well-known and potent cause of birth defects."In some instances taking the drug during pregnancy warrants termination, according to Doering. "There are downsides to that and risks," he said. "But if it were my wife or daughter, I would recommend it."

To exemplify the quality of drug information brought to you by media experts, here is a blast from Paul Doerings past from 2006 Drug Topics magazine, which is particularly salient during the time that Planned Parenthood is being called to task for practices related to what Doering has been quoted as advocating.

Pointing out that OTC Plan B will be sold only in pharmacies and in health clinics, Paul Doering M.S., Distinguished Service Professor of Pharmacy Practice, University of Florida College of Pharmacy, said, "This is one of the times the FDA has publicly acknowledged that there can be or needs to be a third class of drugs. Its a de facto third class of drugs because you cant get Plan B in a convenience store or a supermarket or vending machine."

Doering is skeptical about whether women under 18 will be prevented from obtaining OTC Plan B. "There are no pill polices out there to enforce things. Its voluntary enforcement on the part of pharmacists. Someone may present false identification. If you dont believe these things are hard to enforce, just read an article on underage drinking. The intent is good, but the so-called closed system is going to be more like a sieve with leaks."

Doering said hes not worried about leaks because he thinks Plan B should be available for 14- and 15-year-olds. "Thats the reality," he said. "Keeping it behind the counter and ensuring someone is 18I would take that as a wink and a nod. If someone has a need to get a hold of Plan B, she will."

Pharmer [the bloggers pen name] is hoping that Ms. Silva is now being offered better pharmaceutical care than is available from such media chosen experts as Paul Doering, and that she and her unborn child are spared the consequences of this pharmacy error.

Patients should not be afraid to call up the pharmacy and question any prescription drug which doesnt make sense, or has an unexplained change.

There are no infallible humans, and weve only gotten infallible proclamations three times in 2 millennia from the popes.

Karen L. Brauer, M.S. R.Ph., is a practicing community pharmacist who was fired in December of 1996 from her position as a pharmacist with the KMart Corporation for refusal to dispense Micronor, a progestin-only "minipill," for the purpose of birth control. Karen is the currently president of Pharmacists for Life International, the only pharmacy association which is exclusively pro-life. PFLI is a worldwide apostolate of thousands of pharmacists, plus hundreds of other health professionals, pharmacy students, interns, pharmacy technicians, and the public, in the USA, Canada and worldwide. PFLIs mission is to make pharmacy once again a life-saving profession. As part of this commitment, PFLI is actively involved in educating pharmacists, health professionals, and the public; serving pregnancy care centers; providing an economical speakers bureau; and providing many other benefits for members and non-members, pharmacists, lay persons, and students.